Although several guidelines have stated that patients are not obliged to undergo, and physicians are not obliged to offer, begin, or continue treatments that are futile, there is continuing confusion and controversy about the meaning and usefulness of futility as an indicator for the withholding or withdrawal of treatments.

In this section, the futility of an intervention is to be judged in terms of the clinical goals for each individual patient. The central question is: will the intervention benefit the patient as a whole? Antibiotics will clear up a pneumonia in a patient locked into a persistent state of unawareness. That effect can be achieved. Because this effect can be achieved, some physicians believe antibiotic therapy in this situation is not futile, and hence obligatory. However, what is the goal of treatment for a patient who will never regain consciousness? If the clinical goal of this treatment is to return the patient to even a minimum of intellectual and relational capacity, then this treatment for patients in this state is indeed futile and non-obligatory, for those patients will never return to consciousness and awareness.

It is essential to distinguish and even separate two components in the concept of futility: the component of physiological effect and the component of benefit. Some treatments are futile because they cannot produce a desired physiological effect for a particular patient or a particular category of patients. For example, the probability of chemotherapeutically halting a metastatic process may, on the basis of clinical trial results or on the basis of accumulated clinical experience, be nil or so low as to constitute the rare and unpredictable exception.

Other treatments may be futile because they are useless in attaining the clinical goals of care, even if they can have the effect of prolonging biological life. If the goal of clinical treatment is to restore a patient to a measure of independent life, then treatments are futile if they only prolong a dying process, or preserve the patient in a permanent state of unconsciousness, or tether the patient indefinitely to life-support machines in an intensive care unit.(
Consideration of each individual patient in his or her body and biography, the total patient, is the key to proper use of futility as a criterion for withholding or discontinuing advanced or even basic life support. Prolonging a dying process may be justifiable if the patient and family need that extra time to achieve important personal goals.

Case study One man in an irreversible and advanced stage of leukaemia returned to a hospital time and again for blood transfusions. Some members of the clinical team accused others of excessive agressivity in their treatment of this man. They came to think differently, though, on the day the man returned to hospital one last time, this time to die. He explained that, though he knew the treatments would never cure him, they at least gave him the time to complete the porch he was building around the house for his wife. In a quite different situation, a physician aggressively maintained life support for a severely brain damaged teenager so that the mother and father could synchronize their schedules of grief. The father, unrealistically expecting his son’s return to conscious life, was accusing his more realistic wife of abandoning hope, of abandoning their son. The marriage and the equilibrium of the surviving 9-year-old brother were in danger. The physician, a neurologist, worked carefully and sensitively with the father who, 5 months later, came to the hospital with his wife and son. He apologized to his wife in the presence of the doctor and both husband and wife requested that no further efforts whatsoever be continued to prolong the biological shell of their child. Efforts to prolong the life of a non-salvageable child can be justified, within reasonable limits, if they contribute to the healing of an endangered family life.

Treatments of the most varied sorts are means to ends and the futility of treatments in clinical practice should be judged in terms of how likely it is that any given treatment will obtain the current clinical goals for this patient now.

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